The Dangers of Fat Loss: Embolic Stroke and Retinopathy After Liposuction

Introduction: Liposuction is one of the most common cosmetic surgeries performed, making up 20% of all plastic surgeries performed(1). Liposuction however is not free of complications with an estimated rate of 5% of patients experiencing one (1). Although a majority of these complications are minor in nature, deaths secondary to this procedure are as high as 1 in 5,000 surgeries (2). The most frequent major complications that can lead to death in a patient undergoing liposuction is pulmonary thromboembolism, which represents more than 23% of deaths and believed to be secondary to DVT versus fatty embolism (2). Fat embolism (FE) occurs in up to 8.5% of patients undergoing liposuction, and we must differentiate between 2 pathologies: fat embolism syndrome (FES) and macro FE (3). All patients who have undergone a liposuction of a volume equal to or greater than 900 ml present lipid macroglobulinemia and are therefore susceptible to FES (3). FES is usually gradual, with respiratory, neurological, and cutaneous involvement, which, on average, are presented between 48 and 72 hours after the triggering event (4). The most accepted theory of the pathogeny of FES is endothelial lesions on the walls of small capillaries because of the presence of free fatty acids in the bloodstream, which are very irritating and form microaggregates that activated platelets can adhere, causing a macroscopic (> 3 cm) embolism that can produce a mechanical obstruction (4). Adequate hydration has been shown to reduce microaggregates and protects against FES, therefore is of utmost importance during the procedure (4). Case Presentation: We Present a case of a 57 year old female with liposuction surgery presenting with bilateral vision loss and weakness, that was found to have embolic retinopathy and embolic stroke likely secondary to fatty embolism. The patient underwent a full diagnostic workup that included a physical exam, MRI of the brain and ophthalmic exam. Physical exam showed bilateral limb weakness without loss of sensation. On MRI Multiple foci of diffusion restriction in the bilateral globus pallidus concerning for embolic infarcts (Figure 1). Fundoscopic exam performed showed bilateral with left greater than right ischemic optic neuropathy and loss of vision (Figure 2). The patient was discharged from the hospital after regaining some of her muscle strength and vision in her right eye. She will be following up with ophthalmology outpatient to track her left sided vision loss. Discussion: This case illustrates the importance of adequate hydration during liposuction procedures and the possible side effects of the surgery. Cárdenas-Camarena, Lázaro et al. “Strategies for Reducing Fatal Complications in Liposuction.” Plastic and reconstructive surgery. Global open vol. 5,10 e1539. 25 Oct. 2017, doi:10.1097/GOX.0000000000001539 Grazer FM, de Jong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105:436–446.; discussion 447. Wang HD, Zheng JH, Deng CL, et al. Fat embolism syndromes following liposuction. Aesthetic Plast Surg. 2008;32:731–736. Kwiatt ME, Seamon MJ. Fat embolism syndrome. Int J Crit Illn Inj Sci. 2013;3:64–68.